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Doctors complain they are overworked and underpaid in an underfunded system.

Society admires the dedication of individual doctors. But when the system itself is ailing, Ontario’s 36,000 physicians are endowed with no magical healing powers, nor any monopoly on remedies.

As a lobby group fighting for the financial interests of its members, the Ontario Medical Association has been at war with the government — and itself — for years. Their default narrative is that the province undervalues their hard work, and that the budget is starved of cash.

But which budget?

The overall health-care budget of $54 billion, which soaks up roughly 42 per cent of the nearly $130 billion the government spends on programs every year?

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Or the nearly $12 billion budgeted for physician compensation every year?

The latter figure is a leading indicator (and determinant) of how the overall health budget turns out (and up), because physicians inevitably play the role of gatekeeper: ordering tests, writing prescriptions, booking follow-up visits, referring patients to other specialists.

It is a vital role, for which doctors are highly trained. But the idea that physician pay — not just the agreed fee, but the frequency of billings — should be uncontrolled, ungoverned, and unaccounted for by anyone other than doctors is unsustainable.

And it is at the centre of the ongoing dispute between the government and the OMA, and within the OMA itself.

On one side is the ministry of health, which is headed by doctors: Dr. Eric Hoskins and his deputy, Dr. Bob Bell. On the other side is the OMA, which is also run by doctors.

After years of disagreement, the OMA’s executive finally reached a compromise with the government last summer that boosted the overall physician compensation envelope by 2.5 per cent a year (with a mechanism of clawbacks triggered if the budgeted amount was exceeded).

But the OMA’s then-president, Dr. Virginia Walley, failed to win over the overall membership. Facing open rebellion, she resigned — to be replaced by a leading dissident, Dr. Nadia Alam (president-elect) and the current head, Dr. Shawn Whatley.

The OMA membership and leadership is itself held hostage by members with the most affluence and influence — notably radiologists and ophthalmologists who are profiting from technological advances that allow them to bill faster, higher, than lesser-paid physicians. Attempts to renegotiate the relative gaps in the fee schedule animated last year’s revolt.

That doctors of goodwill on opposite sides of the table — and even on the same side — keep disagreeing with one another is hardly surprising. There are no easy answers to the puzzle of a medicare system that remains our pride and joy but is stuck in time a half-century after its inception.

We are only now taking belated baby steps toward pharmacare, and finally turning our minds — and money — to home care. Denticare — a key component of wellness — remains out of sight and mind. These are the competing pressures on a health-care budget that is imprisoned in the past, treating physicians like the independent contractors they insisted on remaining when a grand bargain was struck in the mid-1960s for universal health care.

That means most physicians are still paid on a fee-for-service basis that takes little account of efficiencies, synergies, outcomes and volumes. It is a piecework system that remains cloaked in secrecy, because the OMA continues to oppose full transparency in disclosing who gets how much from OHIP every year.

Ontario’s doctors argue that they are underpaid, despite being the best paid in Canada. They counter that per-patient fees are lower here, and that their total incomes are high only because their patient volumes are so high. But that is small consolation to a government trying to control costs, or at least reallocate them to get the biggest bang for the buck.

No one doubts that individual doctors work hard. But in aggregate, Ontario needs a system that works smart, not just hard.

A fee for service system that rewards patient volumes over patient vitals is dumb and dated. More than merely gatekeepers, doctors must be partners — and part of an overall system that is integrated and responsive.

Former chief justice Warren Winkler, chosen as a mediator by both sides, warned in 2015 that they were on a “collision course.” The OMA rejected his recommendations summarily, which the government imposed unilaterally. Two years later, they are trying again, with another chief justice set to try mediation and arbitration if necessary.

With nearly $12 billion distributed among more than 36,000 doctors, the stakes are high in lives and livelihoods. In sheer dollar volume the figure is comparable to the annual spending of a major national corporation or government operation, which no one would leave to its own devices.

Doctors cannot be responsible for delivering all the efficiencies that must be found in the system, or to behave like customer service agents at an airport boarding gate. But at some point the government and the OMA will have to come together and acknowledge that if both sides want better patient outcomes, it’s more complicated than providing better pay for doctors.

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